What is the recommended treatment for anxiety in a 14-year-old adolescent?

Treatment of Anxiety in a 14-Year-Old

Start with cognitive-behavioral therapy (CBT) as first-line treatment for mild to moderate anxiety, delivering 12-20 structured sessions; for severe anxiety or when quality CBT is unavailable, initiate an SSRI (preferably fluoxetine or sertraline) or use combination therapy of CBT plus SSRI. 1, 2

Treatment Algorithm by Severity

Mild to Moderate Anxiety

• Begin with CBT monotherapy as the primary intervention, targeting cognitive, behavioral, and physiologic dimensions of anxiety over 12-20 sessions 1, 2
• CBT should include specific components: psychoeducation about anxiety, behavioral goal setting with contingent rewards, self-monitoring, relaxation techniques, cognitive restructuring, and graduated exposure to feared stimuli 2, 3
• Graduated exposure is the cornerstone component for situation-specific anxiety and should be implemented systematically 2
• Approximately two-thirds of adolescents treated with CBT will be free of their primary anxiety diagnosis at post-treatment 4

Severe Anxiety or Significant Functional Impairment

• Initiate combination therapy with both CBT and an SSRI, as this approach demonstrates superior efficacy to either treatment alone 1, 5
• If combination therapy is not feasible, start with an SSRI as monotherapy when anxiety causes significant functional impairment or quality CBT is unavailable 1, 2

Pharmacological Treatment Specifics

First-Line SSRI Options

• Fluoxetine is the preferred SSRI due to robust evidence and FDA approval for pediatric anxiety 2

  • Start at 5-10 mg daily
  • Increase by 5-10 mg increments every 1-2 weeks
  • Target dose: 20-40 mg daily by weeks 4-6
  • Expect statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 2

• Sertraline is an alternative first-line option with strong evidence 1

  • Statistically significant improvement may begin by week 2
  • Clinically significant improvement expected by week 6
  • Maximal benefit by week 12 or later
  • Use slow up-titration to avoid exceeding optimal dose 1

Alternative Medication Options

• SNRIs (venlafaxine, duloxetine) can be offered if SSRIs are ineffective or not tolerated, though evidence is less robust 1, 5
• Hydroxyzine may be appropriate for short-term or situational anxiety management as an adjunct to SSRIs or as monotherapy for milder cases, using the lowest effective dose to minimize sedation 1, 5

Critical Safety Monitoring

Suicidal Ideation Surveillance

• Monitor closely for suicidal thinking and behavior, especially in the first months of treatment and after dose adjustments 2, 5
• The pooled absolute risk of suicidal ideation with antidepressants is 1% versus 0.2% with placebo (risk difference 0.7%, number needed to harm = 143) 1, 5
• The number needed to treat for response is 3, making the benefit-to-risk ratio highly favorable 2, 5

Common Adverse Effects

• Monitor for gastrointestinal symptoms (nausea, diarrhea, heartburn), headache, insomnia, somnolence, dizziness, sexual dysfunction, sweating, and tremor in the first few weeks 1, 2
• Most adverse effects resolve with continued treatment 2
• Behavioral activation or agitation (motor/mental restlessness, insomnia, impulsiveness, aggression) is more common in anxiety disorders versus depression 1

Critical Pitfalls to Avoid

• Do not start with medication alone for mild-to-moderate anxiety when CBT is accessible, as CBT has fewer adverse effects and lower relapse rates after treatment completion 5
• Do not exceed optimal SSRI dosing by titrating too rapidly; the dose-response relationship is logarithmic, not linear 5
• Do not discontinue SSRIs abruptly; gradual tapering is essential to minimize discontinuation symptoms 5
• Avoid benzodiazepines for pediatric anxiety 2
• Avoid paroxetine due to higher risk of discontinuation syndrome and potentially increased suicidal thinking 2
• Avoid tricyclic antidepressants, venlafaxine as first-line, and St. John's Wort 2

Assessment Requirements Before Treatment

• Conduct comprehensive diagnostic evaluation to confirm specific anxiety disorder diagnosis and rule out medical conditions that mimic anxiety symptoms 1
• Use standardized screening tools and collect input from multiple sources (adolescent, parents/guardians, teachers when appropriate) 1
• Screen for comorbid depression, as anxiety disorders co-occur with depressive disorders in 56% of cases 1